Juan M. Aranda Jr., M.D.Professor of Medicine

Medical Director of Heart Failure/ Transplant ProgramUniversity of Florida College of Medicine

Pearls in Acute Heart Failure Management

Best Practices

Disclosures: Nothing to disclose.

Comparison of US and Latin America Heart

Failure Patients

USA Latin America

Age (years) >65 #1 reason for

hospitalization

1.1 million

↑ age >60

999,990

Length of Stay 3 to 7 days 4 to 10 days

HFPEF (ADHERE)

Age

48%

77.2 (66-84)

45.7%

71 (59-71)

Seven Major Classes of Biomarkers Contributing to

the Biomarker Profile in Heart Failure

Braunwald E. J Am Coll Cardiol HF 2013;1:1–20.

Medical Management of Acute Heart Failure

Nohria A, et al. JAMA 2006;287:628-640.

SBP in AHF: Higher is Better?

Gheorghiade M, et al. JAMA 2007

Inpatient mortality from ADHERE Registry Based on admission BUN,

creatinine and BP

Analysis of patients in the National Acute Decompensated Heart Failure National Registry (ADHERE)

BUN=blood urea nitrogen, Cr=serum creatinine, SBP-systolic blood pressure

Fonarow GC et al. J Cardiac Fail 2003;9(suppl 1):S79.

≥

≥

BUN 43(n=32220)

≥

≥

8.35%(n=67640)

SBP 115(n=6697)

15.30%(n-1863)

5.63%(n-4834)

Cr 2.75(n-1862)

13.23%(n-1270)

19.76%(n-592)

2.88%(n=24469)

SBP 115(n=2,702)

5.67%(n=3882)

2.31%(n=20820)

<

<

<

<

Typical 6-Day HF Journey

Day 1

Day 2 Day 5

Day 6

� Admission

� Most of day in

ER

� Diuretic

regimen not

established

until evening

� Diuresis

begins

� Patient feels

better

� Wants to go

home

� Discharge

� Patient

converted to

PO meds

� Feels better

� Still volume

overloaded

More than 50% of Patients Have Little or no Weight Loss

During Hospitalization

Fonarow GC. Rev Cardiovasc Med. 2003; 4 (Suppl. 7): 21

7% 6%

13%

24%

33%

15%

3% 2%

0

5

10

15

20

25

30

35

Pa

tien

ts (

%)

(<-20) (-20 to -15) (-15 to -10) (-10 to -5) (-5 to 0) (0 to 5) (5 to 10) (>10)

Change in Weight (lbs)

Pulmonary and systemic congestion

Background: Congestion and Symptoms in Heart Failure

Abnormal LV function

Increased filling pressures

SYMPTOMS

(Most discharged HF patients)

Heart Failure Admission

High CVP ≅≅≅≅ Elevated Creatinine

Proposed Pathophysiology of Renal Venous Hypertension

(Backward flow)

Ross EA. J Cardiac Failure 2012;18:930-938.

Concept of Plasma Refill Rate in ADHF

Acute Decompensated Phase

Diuretics to increase

sodium loss and decrease

venous pressures

Redefining the Therapeutic Objective in

Decompensated Heart Failure: Hemoconcentration

as a Surrogate for Plasma Refill Rate Boyle and Sbotka J Card Failure May 2006

↓ Intravascular volume↓ Hydrostatic pressure declinesInterstitial pressure + serum

oncotic pressure exceeds luminal hydrostatic pressure

↓

Fluid is reabsorbed

Renal Effects of Angiotensin II

Efferent > Afferent Arteriolar Constriction (PRESSURE EFFECT) Glomerular hypertension / hyperfiltration Proteinuria

Mesangial/Glomerular Constriction (ENDOTHELIAL EFFECT)↓ Glomerular Surface Area↓ Filtration Constant Kf

ProteinuriaProduction renal cytokines,

(eg TGFBETA)Proximal tubule Na reabsorption

Adapted from Douglas JG, American Journal of Physiology 1987.

Afferent

Efferent

Mesangium

AT1 Receptors

SOLVD

Testani JM et al. Circ Heart Fail. 2011;4:685-691.

Prognostic Importance of Early Worsening Renal Function (WRF) after Initiation of ACE Inhibitor in Patients With LV Dysfunction

Early Worsening Renal Function Status: Legend in lower right

B-Type Natriuretic Peptide - A Window to the Heart

Baughman KL. N Engl J Med 2002;347:158-9.

2017 ACC/AHA/HFSA Focused UpdateBiomarkers: Recommendations for Prognosis

Yancy CW, et al. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.04.025.

Biomarkers: Indications for Use

Yancy CW, et al. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.04.025.

Precipitating Factors for HF Decompensation

• Variety of dysrhythmias

• Acute coronary syndromes• Chest pain and nonischemic cardiomyopathies

• Rapid need for increased CO of the failing heart• Infection• Anemia• PE superimposed on chronic HF

• Discontinuation of chronic HF meds

• Progression of underlying disease• CHAMP {ACS, HBP, Arrythmias, Mechanical Cause, PE} ESC HF

guidelines 2016

Key Strategies to Lower HF Readmission Rates

Aranda JM, Jr. CVIA 2015; 1:5-12.

All-Cause Mortality After Each Subsequent Hospitalization for HF

Setoguchi S, et al. Am Heart J 2007;154:260-266.

Sleep Disordered Breathing

Yancy CW, et al. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.04.025.

2017 ACC/AHAHFSA Focused Update: Anemia Recommendations

Yancy CW, et al. J Am Coll Cardiol 2017; doi: 10.1016/j.jacc.2017.04.025.

Conclusions

• Acute heart failure: diuresis until euvolemic

• Understand heart-kidney interactions

• Discharge on appropriate neurohormonal blockade

• New recommendations on BNP, predischarge screen

for anemia, sleep apnea